The challenges of evidence-based prehabilitation in a real-life context for patients preparing for colorectal surgery – a cohort study and multiple case analysis

Background Multimodal prehabilitation programs are effective in reducing complications after colorectal surgery in patients with a high risk of postoperative complications due to low aerobic capacity and/or malnutrition. However, high implementation fidelity is needed to achieve these effects in real-life practice. This study aimed to investigate the implementation fidelity of an evidence-based prehabilitation program in the real-life context of a Dutch regional hospital. Methods In this observational cohort study with multiple case analysis, all patients who underwent colorectal surgery from January 2023 to June 2023 were enrolled. Patients meeting criteria for low aerobic capacity or malnutrition were advised to participate in a prehabilitation program. According to recent scientific insights and the local care context, this program consisted of four exercise- and three nutrition modalities. Implementation fidelity was investigated by evaluating: 1) coverage (participation rate), 2) duration (number of days between start prehabilitation and surgery), 3) content (delivery of prescribed intervention modalities), and 4) frequency (attendance of sessions and compliance with prescribed parameters). An aggregated percentage of content and frequency was calculated to determine overall adherence. Results 58 patients intended to follow the prehabilitation care pathway, of which 41 performed a preoperative risk assessment (coverage 80%). Ten patients (24%) were identified as high-risk and participated in the prehabilitation program (duration of 33–84 days). Adherence was high (84–100%) in five and moderate (72–73%) in two patients. Adherence was remarkably low (25%, 53%, 54%) in three patients who struggled executing the prehabilitation program due to multiple physical and cognitive impairments. Conclusion Implementation fidelity of an evidence-based multimodal prehabilitation program for high-risk patients preparing for colorectal surgery in real-life practice was moderate because adherence was high for most patients, but low for some patients. Patients with low adherence had multiple impairments, with consequences for their preparation for surgery. For healthcare professionals, it is recommended to pay attention to high-risk patients with multiple impairments and further personalize the prehabilitation program. More knowledge about identifying and treating high-risk patients is needed to provide evidence-based recommendations and to obtain higher effectiveness. Trial registration NCT06438484